Contradicting long-held beliefs, a new study published in Hypertension, a peer-reviewed journal of the American Heart Association, indicates that menopause may not be the primary driver of increased aortic stiffness in women after midlife. The research, based on an analysis of the Framingham Heart Study, shows that pulse pressure—the difference between systolic and diastolic blood pressure readings—begins to rise about two decades before menopause, challenging the assumption that falling estrogen levels are solely responsible.
The aorta, the body's largest blood vessel, delivers oxygen-rich blood from the heart to other organs. Over time, its walls can stiffen, leading to wider pulse pressure. A wider pulse pressure means the heart works harder and can damage small vessels in organs like the brain and kidneys. This study found that pulse pressure reaches its lowest point and begins to rise in women in their late 30s, compared to late 40s in men. Importantly, the timing of menopause—whether early, late, or average—had no influence on when this transition occurred.
"Many people believe that the change in pulse pressure is linked to the hormonal shifts caused by menopause. Here, we are evaluating whether the timing of this change, from falling to rising pulse pressure, is connected to menopause timing in a long-term study," said study senior author Gary F. Mitchell, M.D., a longstanding NIH-funded investigator with the Framingham Heart Study and president of Cardiovascular Engineering, Inc. "To our huge surprise, our results suggest that factors other than the timing of the final menstrual period were likely involved in the accelerated increase in pulse pressure in women after midlife."
The implications are significant for clinical practice. Wide pulse pressure is an independent risk factor for cardiovascular disease, dementia, and kidney disease, yet it is not currently included in clinical guidelines for managing blood pressure. "Healthcare professionals should definitely consider pulse pressure in middle-aged and older patients – especially women – with high blood pressure," Mitchell said. He noted that women with a pulse pressure higher than 60 mm Hg, such as 130/70 mm Hg, should be monitored closely, as high blood pressure with wide pulse pressure may be less responsive to standard treatments.
Samar R. El Khoudary, Ph.D., M.P.H., FAHA, who chaired the writing group for a 2020 American Heart Association scientific statement on the menopause transition, emphasized that vascular aging may begin years before menopause. "We shouldn’t wait until menopause to start thinking about cardiovascular health. By the time a woman reaches her final menstrual period, vascular changes may already have been underway for years. Midlife is an opportunity to identify cardiovascular risk early and intervene before disease develops."
The study analyzed data from 6,760 women and 3,248 men in the Framingham Heart Study, a long-term, community-based study supported by the National Heart, Lung, and Blood Institute. Limitations include the observational design, reliance on self-reported menopause age, and a predominantly white European descent sample, which may limit generalizability. The findings underscore the need for earlier attention to pulse pressure in women, potentially reshaping cardiovascular risk assessment and treatment strategies.
